Download Approaches to Developing a Spine Practice in a Saturated Market

Approaches to
Developing a Spine
Practice in a Saturated
Market
J Rafe Sales, MD
Summit Spine Instititute
Portland, Oregon
Disclosures
• Teaching/ Professional Education
– Spinewave, LDR
• Research and development
– Spinewave; LDR
None of these products or concepts are
discussed today or have any part of this
presentation
Market Saturation
• Todays markets are more crowded than
ever
• Many people competing for the same
health care dollars
• To succeed one must find a way to
differentiate from your peers/ competitors
• But how?
Market Saturation
• Three pronged approach
1.Be good
2.Be Different/ Diversify
3.Let people know/ Marketing
“Be Good”
Good”
• Data outcomes and tracking is becoming
more and more prevalent, like it or not
• Doctors will continually be judged by
patients and eventually peers
• Therefore this is part of our business for
the foreseeable future
– Most satisfied patients are more likely to dieReference
“Be Good”
Good”
• So how to you become “good”?
1.Training- stay up to date on the latest
techniques, concepts, and literature
1. This is key in todays competitive marketplace
2. Old techniques, while excellent, are often pushed
aside by educated consumers
2.Track your own data to prove you are good.
1. Can be simple ie: Oswestry, Pain scale pre and
post surgery
2. Can be complicated ie: Patient registry, multiple
patient outcomes tracking modalities
“Be Good”
Good”
• Analyze your data, and be critical
• Usually you need at least one to two years of
data to have enough data to put it out there
• Promote your own data:
1. Patient satisfaction
1. Would you have same surgery again? %, #s
2. Infection rate
1. Compare versus published data
3. Length of stay
1. Compare versus published data
“Be Good”
Good”
• Track “Doctor Websites”
• These unfortunately are also part of your
life and a large number of patients visit
these sites before choosing a doctor
• Have your office manager review sites
monthly or weekly to manage these. If
there is a negative comment or score, you
can often respond with a comment,
apology, etc.
“Be Good”
Good”
• A bad review on a website can undo all
the promotion and word of mouth
• Great reviews can go a long way as well
• One happy patient is good, but one
unhappy patient on the web can be
devastating, so watch these closely
“Be Good”
Good”
• Today young patients will most likely
disseminate the experience through social
media. A happy patient tells 10 people…
• Conversely, a negative physician-patient
relationship, interaction, or communication
will also be transmitted near and far- 100
people
• Therefore watch your reputation online!!
Be Different
“Be Different”
Different”
• Most important concept to differentiate
yourself from the other fish in the pond
• To referring docs, consumers, outsiders,
all spine surgeons/ pain specialists look
the same on the surface
• No one cares where you went to school,
GPA, hair color, training, etc
• Therefore you need to do something to be
different
“Be Different”
Different”
• Offer the latest and greatest (assuming it
is actually good!)
– Goes along with “be good”. Learn new
techniques
– Minimally invasive surgery
– Disc replacements
“Be Different”
Different”
• Many national and international courses
offered, including hands on technique
courses
– NASS – Chicago- Education and training
center
– AAOS- regional training centers
– Industry training courses on new products
“Be Different”
Different”
• Offer services that no one else offers
• Avoid easily copied services
– Valet at hospitals- Good example
– If Hospital A puts one in, Hopsital B will follow
quickly with no net gain
“Be Different”
Different”
• Examples of services no one else offers
1.Satellite Clinics- Often underserved areas
are not that far from your home base, and
have a large patient population and
referral bases
1. Cheap and easy- one to two days a month,
sublease space. With portable EMR this is
now easily added
• Example:
1. Example: San Francisco Spine Institute: Used
to offers a clinic in Northern California/
Redding region for years
2. After clinic stopped, patients still traveled
even 15 years later
1. Average commute to clinic in 2007- 2.5 hours!!
Satellite Clinics
• It’s a way to expand your reach and allow you
to still be successful in your own region
• Summit Spine Institute – Portland Oregon
– Three satellite clinics
• Seaside, Oregon (Oregon coast)
• Hood River, Oregon (The Gorge)
• Newberg, Oregon (Yamhill Valley)
• All surgeries still done at home hospital so it
doesn’t offer coverage issues or other
problems.
Satellite Clinics
• Most important- Not easy to reproduce,
especially for large clinics
• It takes time and effort, and you would be
surprised at how few people will make that
effort
Satellite Clinics
• Newer technology is expanding this further
with telecommunication clinics
• Oregon Health and Sciences University
– Four clinics monthly in Eastern Oregon – 5
hours drive
– Every other clinic is very telemedicine.
– Nurse/ PA on site performs the examination;
Doc interviews patients, reviews imaging, etc.
from Portland
“Be Different”
Different”
• Look outside normal referral sources
– Chiropractors
• Chiropractors often are the gateway to spine care.
• In the NW, more patients present to chiropractors
for back pain, neck pain, than PCPs
• Traditionally there was an adversarial relationship
between MDs and DCs, however this is slowly
changing
• Most spine issues seen by a DC do not need
surgery, however some obviously do.
Chiropractors
• Most chiropractors view surgeons wearily,
and visa versa
• Open communication lines between your
office and chiropractors
– Face to face meetings
– Speak at chiropractic meetings
• Donate $$ to chiropractic societies?
– Give them a familiar face to send herniations,
arm and leg pain, weakness, etc.
Be Different
• Take Workman’s Compensation Cases
– Huge pain in the butt… we all agree. However
this is a very large patient population
– Once your office is well versed in these cases
they will get easier
– Usually good to great reimbursement,
depending on the market
– This goes hand in hand with working with
Chiropractors- they often thrive off MVA, Work
comp cases
Work Comp Keys
• Keys from my practice with work comp
cases
1. Establish rules for handling cases before
accepting them
2. We only become the treating physician once
surgery is approved and only for 3 months
afterwards
3. Medication management for only 3 months
after surgery except for special
circumstances
4. PA/ Office staff can complete paperworkcreate a workflow to make it manageable
Be Different
• Take Motor Vehicle Claims
– Many older physicians/ practices wont take
the claims.. These are also a pain in the butt
– Can take 1 year or more to get paid, and
sometimes you don’t….
• However when they do pay usually they pay at a
rate 2 to 3 x better than commercial payors, so its
worth it.
• Hard to swallow when you first start them because
your AR is so large, but easy to manage $$ and
logistically once a workflow is established
MVA Cases
• Work with the enemy…
– “good attorneys”. It is key to develop
relationships with attorneys who send you
only good cases
• Ie Open claim, insurance coverage, PIP not
exhausted, etc
• If you establish a relationship with four to five good
attorneys usually you can keep a good workflow
coming directly from them
MVA claims
– Once again, these cases go hand in hand with
working with Chiropractors- they often thrive off
MVA, Work comp cases
– Good way to meet new referral sources, as
there is a much smaller pool of competing docs
who accept MVA cases
“Be Different”
Different”
• Find different revenue streams.
• There are many different ways for spine
surgeons to make money aside from
practicing medicine.
• Revenue declines in a saturated market,
so find it elsewhere.
– Product development/ Industry
– Surgery Center Ownership
– Ownership / investment in ancillary services
– Real estate
Product Development
• As surgeons we have insight into how
things work, what needs to be changed,
new ideas, etc.
• Intellectual Property is one of the better
way to gain outside revenue
• Problems:
– Hard to come up with new ideas that have not
been thought of / patented
– How to bring it to market?
Product Development
• Work with companies
– Frowned upon by some. Sunshine Laws
make transparency key.
– Some past decisions/ payments to docs look
very bad- $10 million for BMP-2 research?
Product Development
– Follow the rules and it will all be legal.
• I always use the “front page” test
– Working with companies is one of the ways to
bring your IP to market. They have resources,
labs, etc.
– Or develop a product with your own or local
lab and test it, then bring it to companies to
sell the IP/ concept
• Ie Legacy Lab- Portland Oregon
“Be Different”
Different”
• Use surgery centers/ get involved
• Patients usually like surgery centers
– Higher patient satisfaction
– Lower costs
– Lower complication rates? TBD
Surgery Center Ownership
• Nearly all surgeons either utilize or have
some ownership in a surgery center
• Benefits:
– Revenue
– Better patient satisfaction
– Control over staffing, turnover
– Lower cost to the health care system
Trends in Spine Surgery at ASCs
• Increasing numbers of spine surgeries are
handled on an outpatient basis.
• Overall, outpatient spine surgical rates are
in the 10-15% range.
• By 2015, it is predicted that outpatient
treatments will be nearly as common as
inpatient.
Trends
• Early Pioneers: “bread-and-butter” spine
procedures
– lumbar decompressions and
– cervical
• Current trends:
– Cervical fusions- 1 - 3 levels
– Posterior Lumbar fusions 1 - 2 levels
– Lateral lumbar fusions?
Surgery Center Ownership
• Many different types of centers out there
– Multispecialty Centers- ie orthopaedics,
podiatry, general surgery, pain management,
spine surgery
– Single Specialty Center- ie orthopaedics, pain
management, spine surgery
– Centers that are owned entirely by the
surgeons or a partially owned by either a
surgery center development company or
hospital system
• Ownership % varies based upon type of center you
invest in
Surgery Center Ownership
• Problems / Challenges
– Join an existing center?
• Higher buy in, usually significantly lower %
ownership
– Non-compete- keep in mind this will be quite
rigid so be sure it is a good investment
• 15 miles common in Portland
Surgery Center Ownership
– Start a new center?
• Financial dept/ ownership costs can be substantial
up front
• What is the focus? Single specialty, multi specialty,
etc
• Companies / personnel to help with a new center if
a group needs guidance.
– Start a center with assistance?
• Many companies assist with opening a center
today for a percentage of profits.
Ancillary Services
• As spine surgeons you generate more
than $2 to 4 million in revenue for a
hospital and/ or surrounding medical
community.
• Much comes from ancillary services
– Lab
– Physical Therapy (PT)
– Imaging
– Bracing
– Bone Growth Stimulation
Ancillary Services
• You can get a solid revenue stream from
these sources as well.
• No medicare!
• PT ownership
– Allows input into care style as well
• Imaging– MRI ownership- Very common
– Other imaging services- ? Dexa scanning, CT,
etc
Ancillary Services
• Bone growth stimulators/ bracing
– Unrecognized potential for growth, financial
opportunity
– Only use on cases you would have previously
– Multilevel fusions, nonunions.
• Standard indications
Recovery Units/ SNFs
• This is a growing field in the world of ASCs
and outpatient medicine
• Offer overnight and multiday stay units.
– Allows excellent care that you and your
partners can direct after larger procedures
• Lumbar fusions, multilevel cervical fusions, hip and
knee replacements, etc
– Offers good chance to recoup income that
usually goes to outside companies/ facilities
Real Estate
• Ownership of buildings/ land allows
diversification
– Ownership, either shared or solo, allows
increased revenue, but also increased
exposure
– Allows long term revenue planning as well, as
these “should” increase in value over time
“Let People Know”
Know”
“Let People Know”
Know”
• Really this is marketing for spine
surgeons/ practices, something most of
us know little about.
• The Four P’s of Marketing
– Marketing involves an exchange relationship
between a buyer and a seller
– It is the innovative manner in which practices
apply the four P’s that can differentiate
success and failure.
4 P’
P’s of Marketing
•
•
•
•
•
The four P’s are:
Product
Price
Placement
Promotion
Product
• Goes with the “be good” mantra
• Deliver a good product
– Good care is key
• Deliver a product that is in demand
– Patients want new and cutting edge products
– “Laser” surgery- we all get asked for it. Use
these ideas, don’t fight them!
Price
• Soon we will all be judged by pricing as
well
• Bundling of procedures- its happening!!
• Be ahead of the game
– Work with hospitals to produce bundles
• Better to be early in the game than late
– Work with your ASC to bundle prices to
market to consumers directly ie disc
arthroplasty, etc.
Place
• Goes along with being different.
• If your market is saturated, look to
– underserved area
– “captive audience”- Large company may want
a clinic 1 day a week? GM, Ford, Nike,
Nabisco…..
• A new place is easily entered and will offer
significant opportunity to a incoming
surgeon/ pain specialist.
– Outreach clinics
Promotion
• An ancient Chinese proverb states: “Don’t
stand by the water and long for fish: go
home and weave a net.” If you want
customers, weave your net and surround
your customers with it.
• You want your name/ practice out there for
all to see
Promotion
• Unfortunately promotion is key these days
• Advertise, but advertise well…
– Billboard? Probably not….
• Its okay but it casts a wide net and may not bring
in patients you want
• Expensive!
– Gym or athletic club? Great idea.
– Local Media is good as well
• Local news loves good stories about new surgeries
/ ideas.
Promotion
• The internet? Of course!
• This is where most patients start their
search for care these days.
– Your web site should be good
– Your web site should offer something that
patients need, not just fluff
• Exercise plans, videos of surgeries, etc.
Something that brings them in!
• Costs money but easily recouped.
Promotion
• Other ideas for the net/ promotion
– Smartphone apps
– Google websearch promotion- you want your
groups site to be found first, as most surfers
are lazy!
– QR codes on business cards/ flyers. Direct
patients/ referring docs to your website
Promotion
• Most importantly, promote to your most
important business generators…
– Referring Docs!
– Referring docs usually want two things:
• A good doctor/ service for their patients
• Accessibility
• When docs reach out for guidance, you must be
there and be ready to provide exceptional service.
Promotion
• Referring Docs (cont)
– No one wants to wait a month before being
seen- they will find another doc.
• They will call their doc and tell them that your wait
was too long also- and guess what….
Promotion
– Therefore make your practice accessible for
urgent referrals.
• When new, do it yourself. See patients on short
notice if it means working early/ late
• If a doc calls me to see someone, I will always
offer same day service, even if it kills us, because
next time we will get their referral
• When established, hire ancillary staff to help with
this- NPs, PAs, etc.
Coming Soon…
Soon….
• The promise of consumer-driven
healthcare has been touted for some time.
• The market potential of an informed
patient is envisioned as a “consumer”
equipped with reasonable knowledge of
the medical condition and armed with
quality/ satisfaction metrics of both
physician and healthcare organization and
information about actual cost and pricing.
Informed Consumers
• More and more, patients will have access
to clinical knowledge gleaned from
medical websites, “disease related” forums
on social media, evaluations of provider
quality/satisfaction metrics from a host of
websites, and eventually full financial
transparency from most (if not all)
healthcare providers
Informed Consumers
• The successful clinic/ practice will
recognize and adapt early to this reality
that patients will exponentially want to be
involved as active participants in their own
care.
Internet Consumers
• “In a competitive market, the successful
practice will recognize the fundamentally
changing nature of the physician-patient
relationship. Some will embrace it. Some
will bemoan it. But change is inevitable,
and successful adaptors will do well to
afford the opportunity such a patient
presents”
Summary
• Back to the basics…
– Be Good- Provide a good service that is well
renowned
– Be Different- Be willing to do something that
sets you and your group apart
• From procedures to ancillary services, there are
many ways to be different
– Let people know
• Market yourself!! Go catch the fish…
Thank you!